Diabetic Foot Care Intake & Assessment Form

Diabetic Foot Care Intake & Assessment Form

Managing diabetic foot care requires detailed patient information and regular assessment. This Diabetic Foot Care Intake & Assessment Form helps podiatrists, endocrinologists, and specialized foot care clinics streamline the new patient intake process while ensuring comprehensive screening for neuropathy, ulcer history, and amputation risk factors.

Why This Form Matters for Diabetic Foot Care

Diabetic foot complications are one of the most serious consequences of diabetes, with early detection being critical to preventing ulcers, infections, and amputations. This intake form captures essential medical history, current symptoms, footwear habits, and risk factors in a structured format that supports proper clinical assessment and treatment planning.

Designed for Healthcare Providers

Whether you're a podiatry practice specializing in diabetic foot care, a diabetes clinic, or a wound care center, this template helps you:

• Gather comprehensive medical history including diabetes type, duration, HbA1c levels, and complications
• Screen for peripheral neuropathy with symptom checklists and sensory loss indicators
• Document previous foot ulcers and their outcomes
• Assess current footwear and identify risk factors
• Stratify amputation risk based on clinical indicators
• Identify vascular complications and circulation issues

Streamline Patient Intake with Paperform

Built with Paperform's flexible form builder, this template can be customized to match your practice's specific protocols and branding. The conditional logic ensures patients only see relevant follow-up questions based on their responses, creating a smoother experience while capturing detailed clinical data.

Integration with your practice management system, EHR, or patient communication tools is seamless through Stepper, Paperform's workflow automation platform. Automatically route high-risk patients for urgent appointments, send intake data directly to your medical records system, or trigger follow-up care protocols based on risk stratification—all without writing a single line of code.

Professional, HIPAA-Aware Design

This form template is designed with healthcare best practices in mind, featuring clear medical terminology, logical question flow, and comprehensive data collection that supports quality care delivery. While Paperform is not HIPAA compliant, this template structure can be adapted for use in compliant environments or for initial screening purposes.

For healthcare providers looking to improve diabetic foot care outcomes through better patient intake and risk assessment, this Paperform template provides a professional, efficient starting point that can be deployed in minutes and customized to your exact clinical needs.